Epidemiologic and Clinical Features of Children and Adolescents Aged <18 Years With Monkeypox

United States, May 17-September 24, 2022

Ian Hennessee, PhD; Victoria Shelus, PhD; Cristin E. McArdle, PhD; Maren Wolf, MPH; Sabrina Schatzman, PhD; Ann Carpenter, DVM; Faisal S. Minhaj, PharmD; Julia K. Petras, MSPH; Shama Cash-Goldwasser, MD; Meghan Maloney, MPH; Lynn Sosa, MD; Sydney A. Jones, PhD; Anil T. Mangla, PhD; Rachel E. Harold, MD; Jason Beverley, MS; Katharine E. Saunders, DNP; Jeremy N. Adams, PhD; Danielle R. Stanek, DVM; Amanda Feldpausch, DVM; Jessica Pavlick, DrPH; Megan Cahill, PhD; Victoria O'Dell, MPH; Moon Kim, MD; Jemma Alarcón, MD; Lauren E. Finn, MPH; Maura Goss; Monique Duwell, MD; David A. Crum, DVM; Thelonious W. Williams; Katrina Hansen, MPH; Megan Heddy; Krystle Mallory; Darby McDermott, DVM; Mervin Keith Q. Cuadera, MS; Eric Adler, MPH; Ellen H. Lee, MD; Amanda Shinall; Carlen Thomas; Erin K. Ricketts, MD; Tammy Koonce, MSN; Dana B. Rynk, MSN; Kelly Cogswell, MPH; Meagan McLafferty, MPH; Dana Perella, MPH; Catherine Stockdale; BreeAnna Dell, DVM; Mellisa Roskosky, PhD; Stephen L. White, PhD; Kenneth R. Davis, MPH; Rania S. Milleron, PhD; Skyler Mackey, MPH; L. Anna Barringer; Hollianne Bruce, MPH; Debra Barrett; Marisa D'Angeli, MD; Anna Kocharian, MS; Rachel Klos, DVM; Patrick Dawson, PhD; Sascha R. Ellington, PhD; Oren Mayer, PhD; Shana Godfred-Cato, DO; Sarah M. Labuda, MD; David W. McCormick, MD; Andrea M. McCollum, PhD; Agam K. Rao, MD; Johanna S. Salzer, DVM; Anne Kimball, MD; Jeremy A. W. Gold, MD


Morbidity and Mortality Weekly Report. 2022;71(44):1407-1411. 

In This Article

Abstract and Introduction


Data on monkeypox in children and adolescents aged <18 years are limited.[1,2] During May 17–September 24, 2022, a total of 25,038 monkeypox cases were reported in the United States, primarily among adult gay, bisexual, and other men who have sex with men.[3] During this period, CDC and U.S. jurisdictional health departments identified Monkeypox virus (MPXV) infections in 83 persons aged <18 years, accounting for 0.3% of reported cases. Among 28 children aged 0–12 years with monkeypox, 64% were boys, and most had direct skin-to-skin contact with an adult with monkeypox who was caring for the child in a household setting. Among 55 adolescents aged 13–17 years, most were male (89%), and male-to-male sexual contact was the most common presumed exposure route (66%). Most children and adolescents with monkeypox were non-Hispanic Black or African American (Black) (47%) or Hispanic or Latino (Hispanic) (35%). Most (89%) were not hospitalized, none received intensive care unit (ICU)–level care, and none died. Monkeypox in children and adolescents remains rare in the United States. Ensuring equitable access to monkeypox vaccination, testing, and treatment is a critical public health priority. Vaccination for adolescents with risk factors and provision of prevention information for persons with monkeypox caring for children might prevent additional infections.

During May 17–September 24, 2022, children and adolescents who received a positive polymerase chain reaction (PCR) test result for MPXV, nonvariola Orthopoxvirus (NVO), or generic Orthopoxvirus (OPXV) were identified through national surveillance or during CDC clinical consultations. Demographic and exposure characteristics and clinical features of children and adolescents aged <18 years with monkeypox-compatible symptoms§ who received a positive NVO, OPXV, or MPXV PCR test result were analyzed. In cases for which PCR test cycle threshold (Ct) results were available, persons whose specimens had NVO, OPXV, or MPXV PCR Ct values ≥34 (potentially indicating a false positive test result) and who had atypical clinical features or no known epidemiologic risk factors were excluded.

Data collected included age; sex; gender identity (among adolescents); race and ethnicity; exposure setting and risk behaviors; monkeypox symptoms and lesion distribution; receipt of JYNNEOS vaccine postexposure prophylaxis, tecovirimat (Tpoxx; SIGA Technologies), topical trifluridine (Viroptic; Pfizer Inc.), or vaccinia immune globulin intravenous (VIGIV; Cangene Corporation)**; and hospitalization status. Data were stratified by age group (0–4, 5–12, and 13–17 years). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.††

During May 17–September 24, 2022, 83 MPXV infections were identified among children and adolescents aged <18 years, including 16 (19%) in children aged 0–4 years, 12 (14%) in children aged 5–12 years, and 55 (66%) in adolescents§§ (Table 1). Among 28 children aged 0–12 years, 18 (64%) were boys, and 10 (36%) were girls. Most adolescents were male (48; 89%), six (11%) were female, and information on sex was missing for one. Overall, 38 (47%) children and adolescents were Black, 28 (35%) were Hispanic, 10 (12%) were non-Hispanic White, and five (6%) were of another race and ethnicity; data on race and ethnicity were missing for two.

Among 20 (71%) children aged 0–12 years with available exposure data, 19 were exposed in the household setting; for 17 of these children, the reported exposure was direct skin-to-skin contact that routinely occurs between a child and an adult caregiver. In another instance, fomite transmission (e.g., towels shared with a caregiver with monkeypox) was the suspected route of exposure because the index patient and the child had shared a living space without direct skin-to-skin contact. In the remaining instance, further information about the exposure was unavailable. One nonhousehold exposure occurred when an adult with monkeypox held a child outside the household setting. In two instances, adult caregivers contracted monkeypox after caring for children with monkeypox in household settings; the suspected exposure routes were skin-to-skin contact during diapering and other routine child care activities.

Among 35 (64%) adolescents with available exposure data, 32 were males with direct skin-to-skin sexual contact as the presumed mode of spread: 23 (72%) reported male-to-male sexual contact, four (13%) reported male-to-female sexual contact, and five (16%) reported sexual contact with a person whose sex was not specified. One female adolescent reported recent sexual contact with a male adolescent, but further details were unavailable; another adolescent who identified as a transgender male reported recent sexual contact with a male adolescent. One female adolescent had shared a bed with another adolescent who had a rash, but further details were unavailable.

Among the 28 children aged 0–12 years with monkeypox, lesions most commonly occurred on the trunk; no child had anogenital lesions; 10 (36%) received tecovirimat, one (4%) received VIGIV, and three (11%) received topical trifluridine (Table 2). Two children aged 0–4 years were hospitalized with diffuse rash and eyelid involvement; both recovered without complications and were discharged.¶¶ One child aged 5–12 years was hospitalized for periorbital cellulitis and conjunctivitis; this child received oral tecovirimat and topical trifluridine and recovered.

Among the 55 adolescents, lesions most commonly occurred on the trunk (33, 60%) and the genitals or perianal area (33, 60%). Eight (15%) received tecovirimat. Six (11%) adolescent patients were hospitalized. For five adolescent patients, reasons for hospitalization included pain management, treatment of secondary bacterial infections, and systemic symptoms with rash; three of these adolescents received oral tecovirimat, and whether the other two received tecovirimat is unknown; one adolescent received a new diagnosis of HIV infection during hospitalization. Another adolescent was hospitalized to ensure adequate isolation but had mild symptoms and did not receive monkeypox-directed therapies. All adolescents were discharged and recovered.

Overall, no children or adolescents received ICU-level care or died. No reported case during the investigation timeframe was known to be associated with sexual abuse.

Ten distinct instances were investigated in which a child or adolescent with monkeypox attended a child care facility (two) or school (eight) while symptomatic; no instance of secondary transmission in these settings was identified. JYNNEOS vaccination was offered to close contacts in at least four situations, and in one instance more than 15 other students and staff members received JYNNEOS postexposure prophylaxis.

*These authors contributed equally to this report.
https://www.cdc.gov/poxvirus/monkeypox/response/2022/us-map.html (Accessed October 4, 2022).
§ https://www.cdc.gov/poxvirus/monkeypox/symptoms.html
**https://www.fda.gov/news-events/press-announcements/monkeypox-update-fda-authorizes-emergency-use-jynneos-vaccine-increase-vaccine-supply; https://www.cdc.gov/poxvirus/monkeypox/clinicians/Tecovirimat.html; https://www.fda.gov/media/78174/download; https://www.cdc.gov/poxvirus/monkeypox/clinicians/ocular-infection.html
††45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
§§During the investigation period, CDC received notifications of 109 children and adolescents aged <18 years who received a positive PCR test result for MPXV, NVO, or OPXV, among whom 26 cases were ruled out after further investigation based on high Ct values on NVO, OPXV, or MPXV PCR testing, negative repeat testing, or absence of epidemiological risk factors.
¶¶These children were aged <1 year. Both received oral tecovirimat, and both also received topical trifluridine as potential prophylaxis for ocular monkeypox. One received VIGIV because of their very young age (infant), their immature immune system, and certain other factors.